Geriatric Medicine

Question 1

Acute confusional state is also known as delirium or acute organic brain syndrome. What are the risk factors for developing it?

Answer 1

age > 65 years
background of dementia
significant injury e.g. hip fracture
frailty or multimorbidity
polypharmacy

Question 2

What are the main causes of delirium?

Answer 2

change of environment
infection: particularly UTIs
metabolic: e.g. hypercalcaemia, hypo/hyperglycaemia, dehydration
severe pain
alcohol withdrawal
constipation- consider constipating medications e.g. codeine and ondansetron

Question 3

How is delirium managed?

Answer 3

Tx underlying cause, modify environment, try haloperidol
(unless pt has Parkinsonism)

Question 4

What is involved in a ‘confusion screen’ bloods and why?

Answer 4

B12/folate: macrocytic anaemias, B12/folate deficiency worsen confusion
TFTs: confusion is more commonly seen in hypothyroidism
Glucose: hypoglycaemia can commonly cause confusion
Bone Profile (Calcium): hypercalcaemia can cause confusion

Question 5

Outline the pharmacological management of Alzheimer’s disease

Answer 5

1st line for mild - moderate disease : donepezil, galantamine and rivastigmine (all ACh inhibitors)

2nd line for severe disease / where 1st line is contraindicated: memantine (an NMDA receptor antagonist)

Question 6

Alzheimer’s disease causes widespread cerebral atrophy mainly involving…

Answer 6

the cortex and hippocampus

Question 7

What factors favour delirium over dementia as a diagnosis?

Answer 7

impairment of consciousness
fluctuation of symptoms: worse at night, periods of normality
abnormal perception (e.g. hallucinations and delusions)
agitation, fear

Question 8

Why is a blood screen done in new suspected dementia?

Answer 8

To look for reversible causes

Question 9

How does Lewy-Body dementia typically present?

Answer 9

Dementia, visual or auditory hallucinations, delusions and Parkinsonism

Fluctuating cognition

Question 10

Give some risk factors for multi-morbidity

Answer 10

increasing age
Female sex
Low socioeconomic status
Tobacco and alcohol usage
Lack of physical activity
Poor nutrition and obesity

Question 11

What is the most common comorbid condition?

Answer 11

Hypertension

Question 12

Define fraility.

How should it be assessed?

Answer 12

Frailty is defined as a state of impaired homeostasis leading to increased vulnerability to minor stressor events.

through the evaluation of gait speed, self-reported health status, or the PRISMA-7 questionnaire

Question 13

What is the GPCOG test?

Answer 13

a test designed as a GP screening tool for dementia

Question 14

What is the Waterlow score?

Answer 14

Used to identify patients at risk of pressure sores

Question 15

What is the clinical frailty scale? How is it helpful?

Answer 15

Set of 9 phenotypes ranging from very fit to terminally ill which can be used to summarise the older patient’s overall level of fitness or frailty and predict outcomes of survival/prognosticate

Question 16

What is a CGA?

Answer 16

comprehensive geriatric assessment —> Multidimensional, interdisciplinary diagnostic processes to determine the medical, psychological and functional capabilities of frail older people to develop a coordinated & integrated plan for treatment and long-term follow up

Question 17

What are the “geriatric giants”?

Answer 17

Immobility
Instability/falls
Incontinence
Impaired memory (dementia, delirium)
Iatrogenesis

Question 18

What are the domains of a CGA? (7)

Answer 18

o Problem list – current and past
o Medication review
o Nutritional status
o Mental health – cognition, mood and anxiety, fears
o Functional capacity - basic activities of daily living , gait and balance, exercise status
o Social circumstances
o Environment - home environment, facilities and safety within the home, accessibility to local resources

Question 19

What are the complications associated with delirium?

Answer 19

increased mortality, prolonged hospital admission, higher complication rates, institutionalisation and increased risk of developing dementia

Question 20

How can delirium be categorised?

Answer 20

hyperactive (agitated and confused), hypoactive
(withdrawn and drowsy) or mixed.

Question 21

Faecal incontinence in the elderly is always abnormal and usually curable. What is it most commonly caused by?

Answer 21

faecal impaction with overflow diarrhoea. This accounts for 50% of faecal incontinence. The second most common cause is neurogenic dysfunction

Question 22

Which tool is used to assess the risk of stroke in the short term post TIA?

Answer 22

The ABCD2 score

The ABCD2 score is calculated by summing up the points for five different factors including age, blood pressure, clinical features, duration of symptoms and the presence of diabetes. ABCD2>=4 indicates a higher risk.

Question 23

Give some indications that a patient is reaching the end of life

Answer 23

o Bed bound.
o Semi-comatose.
o Only able to take sips of fluid.
o Unable to take medicine orally

Question 24

Alzheimer’s disease is the most common cause of dementia. How does it present?

Answer 24

Insidious onset with slow progression. Behavioural problems are common. Diagnosed on clinical history but brain imaging may show disproportionate hippocampal atrophy.

Question 25

Vascular dementia is the 2nd most common cause of dementia. Give its key features

Answer 25

Suggested by vascular risk factors e.g. hypertension. Imaging is suggestive of vascular disease. Often has a step wise progression.

Question 26

How does frontotemporal dementia typically present?

Answer 26

Onset often early e.g. in a younger person with fam hx

often associated with complex behavioural problems, language dysfunction may occur

Question 27

Give some physical manifestations of frailty

Answer 27

Sarcopenia- loss of skeletal muscle, fat mass may be preserved
Unintentional weight loss- disease, ill fitting dentures, inability to make or eat meals
Fatigue

Question 28

Define delirium.
How do you assess for it?

Answer 28

Acute and fluctuating changes to consciousness, cognition or perception

4AT score

Question 29

What non pharmacological interventions can help with delirium?

Answer 29

Reassurance
Consistency
Orientation – clock, pictures, talking, stimulate, family
Avoid transfer between wards / less moves
Minimise sensory deprivation/overload – ear wax, hearing aids
Safe wandering
Sleep hygiene – scheduled med rounds, overnight interventions

Question 30

Outline the concept of polypharmacy and how to approach prescribing in the elderly

Answer 30

Polypharmacy is the concurrent use of multiple medications. Polypharmacy in advancing age frequently results in drug therapy problems related to interactions, drug toxicity, falls with injury, delirium, and nonadherence. It is associated with increased hospitalizations and higher costs of care.

Reduce dose- often start at 50% of the adult dose
Review regularly (can use STOPP START)
Give clear instructions

Question 31

4 medications used in palliative care?

Answer 31

opioid e.g. morphine
anti-emetic
anti-secretory - glycopyrronium
sedation - benzodiazepine